A survey and knowledge assessment of Albertan pharmacists providing pharmacy services to athlete-patients

Introduction

Medication usage among athletes is common.^1-4 The World Anti-Doping Agency (WADA) publishes a list of medications that are prohibited either in competition or out of competition or are prohibited in a sport-specific manner. ⁵ Athletes take a variety of different medications and supplements in an attempt to maximize performance without infringing on the prohibited list. ⁶ As athletes are ultimately responsible for ensuring that medications ingested are not prohibited, this delicate balance can be difficult for them to navigate independently. ⁶

In 2014, the International Pharmaceutical Federation (FIP) adopted guidelines on the role of the pharmacist in sport. ⁷ Among other recommendations, FIP recommends that pharmacists should: (1) keep up to date with the WADA list; (2) remain vigilant to differentiate justified use of medication and illegitimate practice; (3) when informed a person participates in competitive sport, enter that information into the person’s medical record; (4) help individuals recognize which medications contain a substance included in the WADA list; and (5) provide information to those involved in athletic sports on the benefits of nutritional supplements and the risks associated with using them. ⁷

The involvement of pharmacists in the management of medications in sport has been documented in the literature. Specifically, pharmacists have been involved in doping prevention and injury management. ⁸ In Alberta, pharmacists can acquire the credentials, known as additional prescribing authorization (APA), to independently prescribe medications that are federally regulated to require a prescription from an authorized prescriber (i.e., a prescription medication). Thus, Alberta pharmacists have an excellent opportunity to manage and prescribe medications for athletes. Pharmacists must be aware and knowledgeable to ensure that medications that they are prescribing, recommending or dispensing do not result in an athlete inadvertently taking a banned substance.

The objective of this survey was to explore Alberta pharmacists’ current role and knowledge in providing medication usage guidance and medication prescribing for athlete-patients.

Methods

A descriptive study using a cross-sectional anonymous web-based survey tool (Qualtrics) was conducted. The survey was distributed to all pharmacists registered with the Alberta College of Pharmacy who agreed to have their emails available for research purposes. An initial email was sent out (April 1, 2022) with 2 reminders (April 11 and April 25, 2022). Survey participants were given 4 weeks to complete the questionnaire. Inclusion criteria was any pharmacist currently practising in Alberta and registered with the Alberta College of Pharmacy.

Survey questions were adapted from a survey by Yee et al., ⁹ with the addition of 3 questions related to practice in Alberta, including independent prescribing (indicated as APA). The survey questions are included in Appendix 1 (available in the Supplemental Materials section). Descriptive statistics were used to analyze the survey questions.

Ethics approval was obtained by the University of Alberta Ethics Board (Pro00117342). This study was funded by the University of Alberta Faculty of Pharmacy and Pharmaceutical Sciences.

Results

A total of 342 of 5668 pharmacists registered with the Alberta College of Pharmacy and who consented to provide their email address for research purposes completed the survey (response rate 6%). Some respondents did not answer every question. Participant demographics are displayed in Table 1.

Table 1.

Demographic information for survey participants^*

Demographics	Frequency (%)
Primary workplace
Community	237 (69)
Hospital	76 (22)
Other	32 (9)
Have additional prescribing authorization (i.e., able to prescribe a prescription medication)
Yes	228 (67)
No	114 (33)
Graduated from
Alberta	225 (66)
Canada (other than Alberta)	53 (15)
Outside Canada	64 (19)
Years of practice
0-5	120 (35)
6-10	55 (16)
11-15	44 (13)
16-20	34 (10)
20+	89 (26)
Frequency of watching televised sport
>Once per week	133 (39)
>Once per month	57 (17)
Approximately once per month	41 (12)
Less than once a month	111 (32)
Aware of athletic sanctions for inappropriate medication usage
Yes	322 (94)
No	20 (6)
Recall being taught about sports/athletic pharmacy in entry-to-practice degree
Yes	38 (11)
No	303 (89)

^*Absolute number (percentage).

Table 2 displays the results of the knowledge assessment of drugs used in sports based on the WADA Prohibited Substances List.

Table 2.

Correct responses to pharmacists’ knowledge assessment on banned medications during competition in sport^*

Medication or therapeutic class	Correct answer to query	Number of respondents with correct answer in our survey (%)	Percentage of respondents with correct answer in Yee et al. 9 (%)	Percentage of respondents with correct answer in Voravuth et al. 10 (%)
Anabolic steroid	Banned	335 (98)	(99)	(95.8)
Nonsteroidal anti-inflammatory drug	Not banned	329 (96)	(90)	(91.4)
Diuretic	Banned	157 (46)	(84)	(55.5)
Darbepoetin	Banned	225 (66)
Proton pump inhibitor	Not banned	337 (99)	(98)
Central nervous system stimulants (e.g., methylphenidate)	Banned	270 (79)	(96)	(78.6)
Acetaminophen	Not banned	342 (100)	(99)

^*Absolute number (percentage).

A total of 27 (8%) of respondents recalled using their APA to prescribe a prescription medication to an athlete, while 135 (39%) remembered recommending an over-the-counter product to an athlete. In addition to this, 85 (25%) participants remembered having reviewed the WADA list of prohibited substances in sport, and 31 (9%) were familiar with the Global Drug Reference online search engine. A total of 289 respondents (85%) indicated that they did not feel they have adequate knowledge to treat and educate a patient on performance-enhancing medications.

Discussion

In this study, we describe the knowledge and practice of Alberta pharmacists regarding sport and medication use. We found that pharmacists were not familiar with drugs banned during competition, both by responses to knowledge questions and self-report. In addition, most respondents were not familiar with the online resources available to assist with appropriate medication use in sport. This is supplemented by the fact that nearly 90% of respondents did not recall being explicitly taught about sports/athletic pharmacy during their pharmacy education. Taken together, this demonstrates a possible knowledge gap among pharmacists when providing pharmacy services to the niche athlete-patient population. While a small percentage of respondents (8%) reported having knowingly prescribed a prescription medication to an athlete, nearly 40% recalled having recommended an over-the-counter medication. It is beyond the scope of this survey to explore the appropriateness of these interventions. Given that a pharmacist’s assessment may not uncover that a patient is an athlete, as the onus to supply this information to the pharmacist should be the athlete (which may not always occur), it is possible that these proportions underrepresent the true proportion of pharmacists who have provided pharmaceutical services to athlete-patients.

The results of our survey are similar to those presented in the literature. A review by Hooper et al. ⁸ found that while pharmacists viewed themselves as a good potential source of information for athlete-patients, few pharmacists report having the necessary knowledge, access to reliable information, confidence to discuss doping with athletes, time to engage athlete-patients and adequate product selection stocked at the pharmacy outlet. Among surveyed pharmacists in France, 74% of respondents considered themselves poorly or very poorly trained in doping prevention, and only 6% reported having had specific university education that addressed this. ¹¹ Howard et al. ¹² documented that of surveyed pharmacists, 26% indicated that they had received some formal education on sports supplements in pharmacy school. This is similar to our survey documenting that 11% of respondents recalled being explicitly taught about sports and athletic pharmacy in their entry-to-practice degree. Some authors have recommended that medications for human sport performance be incorporated into the existing pharmacy curriculum, with elective sport pharmacy courses taught for students with a keen interest. ⁶ In our survey, we asked respondents to describe how pharmacists could become more involved in providing guidance for athletes, and the vast majority of submissions included the request for some form of additional education (either during pharmacy school or postgraduate continuing education courses). The results of our survey can be used to help guide pharmacy school curriculum decisions and the creation of continuing education material to build skills and advance knowledge acquisition in Canada and to promote awareness among the pharmacist community.

The results of our knowledge assessment compared to similar surveys is presented in Table 2. We structured our survey similarly to the Yee et al. ⁹ survey but asked several questions pertaining to pharmacist prescribing for athlete-patients, given our unique practice model in Alberta. Yee et al. ⁹ had a similar community and hospital pharmacist representation in their survey compared with our sample. Voravuth et al. ¹⁰ reported a cross-sectional survey of community pharmacists in Malaysia. Across all 3 surveys, pharmacists consistently demonstrated awareness that anabolic steroids are banned and nonsteroidal anti-inflammatory drugs, proton pump inhibitors and acetaminophen are not banned during athletic competition (according to WADA).^9,10 However, there were some differences. Our sample, along with Voravuth et al., ¹⁰ showed that approximately 50% and 80% of respondents were able to correctly indicate that diuretics and central nervous system stimulants are banned, respectively. This is compared with Yee et al., ⁹ who showed that 84% (diuretics) and 96% (central nervous system stimulants) of respondents correctly answering this question. The rationale for the overall large number of respondents who incorrectly answered the question on diuretics and central nervous system stimulants while correctly answering the question on anabolic steroids is unknown. There are 2 possible reasons for this. One, anabolic steroids, compared with diuretics and stimulants, may be more socially known as banned substances in sport, and respondents were able to correctly identify this based on social influences rather than formal training or knowledge. Two, diuretics and central nervous system stimulants do not result in physical advantages in the way that anabolic steroids might. Diuretics are illegitimately used in sport for 2 reasons. They are used to rapidly eliminate water, resulting in weight loss for athletes to meet specific weight targets, and can also be used to dilute the urine, potentially masking other drugs and metabolites. ¹³ Central nervous system stimulants are illegitimately used in sport to reduce tiredness and increase alertness, competitiveness and aggression. ¹⁴ Given that these 2 drug classes are not acting to promote muscle growth and strength, as in the case of anabolic steroids, there may be less awareness among pharmacists about the misuse of these drug classes in sport.

This study is not without limitations. First, our response rate of 6% potentially limits the generalizability to the broader Alberta pharmacist population. However, our response rate was similar to the response rate reported by Voravuth et al. ¹⁰ (12%) and Yee et al. ⁹ (10.6%). In addition, our knowledge assessment had similar correct response rates to the studies by Yee et al. ⁹ and Voravuth et al., ¹⁰ suggesting knowledge gap themes irrespective of the geographical location and local practice environment. Second, our knowledge assessment was not controlled against individuals using the WADA list to correctly answer the knowledge assessment. However, given that less than 50% of respondents were able to correctly answer the question on diuretic use in sport, we do not believe this to be a major factor influencing our results. Lastly, there may be responder bias present in this survey. Our survey documented that 94% of respondents were aware that sanctions have occurred against athletes for using prohibited substances in sport and 25% have previously reviewed the WADA list of banned substances. This may reflect a higher percentage in this sample compared with the larger Albertan pharmacist population, as pharmacists with an interest in medication usage among athletes may have been more likely to complete the survey.

Conclusion

Our survey results demonstrate that a potential knowledge gap exists among pharmacists in Alberta with respect to providing pharmacy services to athlete-patients, as shown by a knowledge assessment and self-report. Compared with the international literature, results from our knowledge assessment reveal a similar knowledge gap among pharmacists related to prohibited drug use in sport. This is possibly related to the social prominence of anabolic steroids compared with other prohibited drugs such as diuretics and central nervous system stimulants. Lastly, our survey documented a desire among Albertan pharmacists for further educational opportunities pertaining to appropriate medication use in sport for athlete-patients.